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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. y�so N. Job Address - Cit Lot Size PM Owner's Name ut Address Sa Phone� 7�' V O Ll Contrac r Address f J License No Z9ZZ6, Phon - 0-, �a� TYPE OF WELL/PV P: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ k - DISTANCE TO NEAREST:,SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP._LINE_ ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 6, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications FI I Public l� Other I� Delta Depth of Grout Seal " * -•-Type of Grout I I Irrigation —Approx. Depth I Eastern Surface Seal Installed by .. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth ~ '° 'Filler Material (Below 50'l TYPE OF SEPTIC WORK: NEW INSTALLATION RCPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is 4t `•; f Y' . ? available within 200 feet.) Installation will serve: Residence'Commercial:A Other ! T 3 Number of living units: Number o e rooms, Character of soil to a depth of 3 feet: Water table depth/",)o SEPTIC TANK Type/Mfg CapacityZ_)_ No. Compartments PKG. TREATMENT PLT. ❑ c'+ __ r �; _ -Method..of Disposal - Distance to nearest: Well `Foundation 1Q, Property Line LEACHING LINE ?a LI No. & Length of lines ^' Total length/size FILTER BED Distance to nearest: Well es Foundation Property.Line SEEPAGE PITS � Depth- Y _ Slze -^ Number,- �.,. �i•. . SUMPS ❑ Distance to nearest: `Well':/�fyFou ndation. �; ._ property Lines DISPOSAL PONDS ❑ t I hereby certify that I have prepared this application and that the-work will be done in/accordance with San./Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di1trict. r •. Home owner or licensed agent's signature certifies'the4ollowing:,"I certify that,in the performance of the'work for which this permit is issued, I shall not employ any person in such manner as to becorne-subject to workman's compensation laws of California.-rnia." Contractor's hiring or sub-contracting signatur certifies the following: "I certify that in the perforr'nance'of the.work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mustII for al uirenspect�ions'Co�mplate drawing on reversed . k.Signed X Title: � � Y Date• 4d FOR DEPARTMENT USE ONLY' Application Accepted by Date- Area tt r Grout Inspection by Data �Pnal Inspectionf�by Additional Comments: ❑ Silk 466-6781 0-Lodi- 369-3621 ❑ f,+bnteca 823-7104 ❑ Tracy- 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT%NO. INFO CASH � f�i +.EH 13-24 MEV.t i n s) d 9 q ,�EH 14-26